DME requests pose practice problems

Mark Braun, MD, FACP, doesn't know whether the authorization request for a back brace was initiated by his patient, perhaps after seeing an advertisement, or suggested by the company involved. “She didn't call me and say, ‘My back pain is getting worse. What can we do?’,” he said.

Instead, a durable medical equipment (DME) company sent the request, asking him to authorize a brace on the patient's behalf. Like other DME requests, that authorization query set off a chain reaction of checks and cross-checks for Dr. Braun's Rhode Island practice. He first asked a staff member to research the largest size offered by the company, given the woman's size. Then he asked someone to call the patient and get her waist measurement.

That sort of detective work can be time-consuming, Dr. Braun said. “What it does to primary care physicians is it increases our burden of work substantially, because we are being asked to evaluate and potentially authorize services and supplies that we didn't think were actually necessary in the first place.”

In recent years, durable medical equipment has been on the investigative hot seat. A 2012 Government Accountability Office (GAO) report found that 16% of criminal investigations conducted in 2010 for public programs like Medicare and Medicaid involved DME suppliers. Federal officials also have scrutinized orders for some power wheelchairs, with a 2011 Office of Inspector General report determining that 9% weren't medically necessary.

But physicians like Dr. Braun say a more common scenario is when they get an order for a relatively inexpensive item via a DME provider and then are faced with the problem of determining how much staff time they should invest in assessing medical need. Primary care doctors and orthopedic surgeons are particularly likely to field requests for such items as braces or multiple diabetic supplies, Dr. Braun said.

“Some don't want to be bothered and they just sign it, to make them go away,” he said. “Others take the opportunity to contact the patient and see if the patient actually requested that piece of equipment that they're signing for. Sometimes it's the case that the patient has actually requested the equipment. But oftentimes, the patient knows nothing about it.”

Assessing need

Meanwhile, the documentation requirements for some DME items are becoming more rigorous for physicians caring for Medicare patients, as federal officials implement related provisions of the Affordable Care Act.

Under one of those new requirements, which went into effect in July 2013, doctors are required to document in writing prior to delivery why a patient needs 1 or more on a designated list of DME items. (Those items, listed in the Federal Register, range from hospital beds to seat lift mechanisms to manual wheelchair accessories.)

Doctors also are required to document an in-person assessment within a 6-month period before the DME order to determine if the patient would benefit. The face-to-face requirements are in effect but won't be enforced until a date to be determined later this year, according to a spokeswoman at the Centers for Medicare & Medicaid Services (CMS) this spring.

The spokeswoman declined an interview request to discuss the parameters of the new requirements. But the underlying rationale for increased documentation and the face-to-face encounter is to more directly tie the patient's need to the physician's order of the item, according to comments by federal officials provided in the final rule, issued Nov. 16, 2012.

Federal officials cited another GAO report, which estimated $700 million in improper Medicare payments for DME items during a 1-year period ending in March 2006. The report didn't specifically recommend face-to-face assessment, federal officials noted, but suggested that steps should be taken to reduce improper payment issues. The improper payments, 7.5% of all DME payments by Medicare, involved mistakes, fraudulent activities, and abuse, according to GAO officials.

At this point, the list of covered items is limited and doesn't include orthotics and prosthetics. The regulations also allow several other categories of clinicians to perform the face-to-face assessment, including physician assistants, nurse practitioners, and clinical nurse specialists. Eileen Moynihan, MD, FACP, a medical director at Noridian Healthcare Solutions, LLC, one of the contractors that processes DME claims for Medicare, said her understanding is that CMS officials are looking at how that face-to-face assessment will be accomplished by those nonphysician clinicians.

When describing a patient's need for medical equipment or supplies in the medical record, physicians don't have to have an in-depth knowledge of all of the aspects of those items, Dr. Moynihan said. Rather, they need to provide sufficient detail about the patient's condition and limitations so that his or her DME need can be inferred.

Take someone with a heavier build who requires a manual wheelchair and would benefit from some specific features, such as elevated leg rests, Dr. Moynihan said. In the medical record, the doctor could describe the patient's leg swelling and larger size but would not have to specify wheelchair models, she said.

“The support in the note is really as a check against overly supplying to the patient more than the patient needs,” she said. “It's a check and balance.”

Noridian is educating doctors about the new requirements through information on its website and plans to do further outreach to physician groups as well, Dr. Moynihan said.

But to date, physician education by CMS has been “extremely limited,” and doctors are frequently surprised by the level of documentation now required, according to Cara Bachenheimer, a senior vice president of government relations at Elyria, Ohio-based Invacare Corp., which manufactures wheelchairs, lift devices, and other equipment. “There is a huge lack of awareness in the physician community,” she said.

Plus, physicians who do know about the new regulations may find themselves confused by the specifics, Ms. Bachenheimer said, since some items still don't require a face-to-face assessment and those that do may have differing time frames. For example, she said, a prior regulation stipulates that the face-to-face assessment for power wheelchairs must occur within 45 days rather than the 6 months called for the additional items covered by the new regulations. Another Medicare requirement stipulates that the treating physician must evaluate the beneficiary within 30 days prior to prescribing home oxygen therapy.

Practice logistics

Yul Ejnes, MD, MACP, an internist in Cranston, R.I., past chair of ACP's Board of Regents, and a member of ACP Internist's editorial board, admits to being conflicted about the increased documentation. On the one hand, doctors have a responsibility to vet these DME requests rather than taking the path of least resistance by just signing off, he said.

But, he countered, “I think it's a bad thing that the doctors have been put in the position of being policemen for CMS. If there is fraud and abuse going on, then they need to find it and deal with it. Deputizing us to be the policemen is not the way to go about it.”

Like Dr. Braun, Dr. Ejnes already asks a member of his staff to follow up if a DME request unexpectedly appears, “just to ferret some of this stuff out,” he said. One pattern he's noticed in a few cases involves patients with diabetes who are already working with a DME provider and are told they might be eligible for other nondiabetic items.

While the face-to-face requirements are designed to reduce federal spending on unnecessary equipment, Dr. Braun questions some of the practical logistics involved. If he's requested a wheelchair, for example, documenting the need for a device he's already ordered requires extra effort. But if the device has been requested by another clinician, then payment is put at risk if Dr. Braun doesn't document that a face-to-face assessment has occurred.

“It's not fraud,” he said. “It's just that I'm being asked to attest to something I can't attest to. That puts me in a very awkward position.”

One step that doctors can take to reduce unanticipated DME orders is to educate patients that they'll need to inform the doctor first if they're interested in a particular DME item, Dr. Moynihan said. Otherwise, a patient might trigger an order process by visiting a DME supply store, and then the doctor needs to bring the patient back to evaluate his or her clinical need.

“It might be weeks before you can, because of how busy you are,” Dr. Moynihan said. “And you could have taken care of it when the patient was in the office, had you known.”

Sometimes patients are the first to acknowledge that a particular DME item was never their idea, Dr. Ejnes said. In other circumstances, it might not be the best option for them clinically, he said. For example, a back brace that's worn too frequently can restrict a patient's movement in ways that could atrophy muscles.

Or, as in the case that Dr. Braun described, the patient may not be a candidate for other reasons. A couple of weeks passed before the patient called back with her waist size, which considerably exceeded the back brace limit, he said. As far as Dr. Braun knows, the patient never followed up.

Spotting DME fraud

Durable medical equipment (DME) investigations have increased in recent years, with the highest number of questionable claims involving New York, Michigan, California, and Florida, according to a 2012 report by the National Insurance Crime Bureau (NICB) looking at claims from 2009 through 2011. The analysis by the Des Plaines, Ill.-based non-profit organization, which partners with investigators and insurance companies, identified a litany of common DME fraud patterns, including:

• additional DME items added to the prescription or the invoice without the clinician's or patient's knowledge,
• a “goody bag” given to patients regardless of medical necessity,
• “pre-made” prescription pads provided to doctors that are designed to allow only higher-end items,
• bills submitted for DME that the patient never receives,
• shell company scenarios, such as vacant storefronts and suppliers that only exist on paper, and
• charging the purchase price for a DME item only needed for a short time, while not disclosing that rental is available.

Vincent Nitti, a special agent with NICB who investigates medical fraud, stressed that he only encounters the bad actors. “The vast majority of DME providers are legitimate and the doctors that are providing it are legitimate,” he said.

To guard against DME fraud, doctors should verify that they are dealing with a legitimate DME company, one that has a physical location and doesn't exist solely on the Internet, he said. Also, verify that the quality of the equipment matches the price, he said.

For example, if the doctor ordered a high-end knee brace, did the patient show up in something more closely resembling an elastic bandage? When feasible, specify the type of brace. Otherwise, Mr. Nitti said, “An unscrupulous DME provider will provide the cheapest one and charge for the most expensive one.”